Clinical and claims data must be in synch to achieve best outcomes for patients
Data is the backbone of every health care decision. Various regulations, initiatives, and platforms seek to unlock data from separate silos for free-flowing exchange that enhances the patient experience and enables data-driven improvements in health outcomes.
Health plans and providers remain invested in using data to achieve improved care coordination while lowering costs, tenets of value-based care (VBC). As stakeholders team up to garner deeper, more holistic views of each patient to provide optimal treatment, here are five adoption habits that will guide the essential transition to VBC.
Partner for success
When VBC first entered the health care scene, health plans were the only stakeholders focused on ensuring that patient populations were well managed. Today, clinicians are also investing in VBC by entering into contractual relationships with payers for risk sharing.
To reduce overall costs of care and provide useful programs to help patients, a provider’s clinical data and a payer’s claims data must be leveraged for a complete understanding of high-risk patients and their needs. By leveraging this rich data set, health systems can ensure patients are able to take advantage of member programs that best suit their needs. But since it can be costly to gather, normalize and act on data, providers must remember both to seek guidance of experts and use caution when entering into risk-sharing arrangements with health plans. If these arrangements are not run efficiently it could lead to potential losses due to downside risk.
Consider all the data
While clinical and claims data are essential for health care decision-making, providers are also relying more on social determinants of health (SDOH), the non-medical behaviors, circumstances, and demographic factors that influence a patient’s outcomes. After the Centers for Medicare & Medicaid Services (CMS) issued guidance designed to drive adoption of strategies that address health disparities, clinicians have begun to use SDOH to further guide treatment decisions. CMS made this decision in part to advance VBC. Partly as a result, clinicians now are using data about factors such as environmental challenges, likelihood of adherence, and motivational factors are leveraging data to help stratify patients and tailor interventions.
In April 2022, CMS unveiled an action plan for providing high-quality, affordable health care for all Americans and driving health equity. CMS Administrator Chiquita Brooks-LaSure acknowledged that the country can only reach these goals by partnering with industry. The plan includes sharing best practices across states, health care facilities, providers, insurance companies, pharmaceutical companies, people with lived experience, researchers, and other key stakeholders to drive commitments for advancing health equity.
This bigger picture view of a patient’s life enables health care decision-makers to drive effective program participation. Whether it’s providing ride-share coupons or telehealth to help resolve transportation challenges, mail-order prescriptions to combat non-adherence, or increasing enrollment in food stamp programs so that patients don't need to choose between eating and filling their prescriptions, providers can integrate these solutions into traditional care delivery models to improve outcomes.
Integrate data for execution
Identifying appropriate data sources and partnerships is critical to VBC success, but it requires the ability to analyze and apply the data for informed decision-making. Inability to exchange data among many health care data silos creates numerous challenges and inefficiencies in this regard. Various solutions seek to ensure data flows smoothly between systems for integration, but execution is key.
Typically, each provider organization uses numerous systems, and patient data is stored on multiple platforms among outside providers, payers, electronic health record (EHR) systems, billing and laboratory information systems, and so on. But while interoperability among them is a huge problem, it is important to remember that interoperability is just the beginning, not a goal unto itself.
The depth of the data is what truly matters as stakeholders attempt to access and integrate various silos. To get patients the programs they need and the care they deserve, payers and providers must allocate the resources to guarantee the right care at the right time to the right people. These types of tailored and meaningful patient interventions rely entirely on access to high quality and complete data.
Surface gaps at the point of care
One of the most important roles of data in VBC is helping to reveal comprehensive care gaps. Once a recommended best practice is missed, it is difficult to retrospectively fix the problem with separate outreach and visits. Identifying gaps right at the point of care is the most effective way to manage patients — particularly those with complex medical or chronic conditions.
Providers that build best practice recommendations for specific patient conditions into the workflow of regular visits will be the most successful at ensuring the patient takes the required next steps. By preparing a list of to-dos as a patient is registering or while making their subsequent appointment, providers facilitate a patient’s use of key preventative care or other necessary medical procedures. The data prompts, the provider facilitates, and the patient executes. The health plan, provider and patient all benefit from closing gaps of care to further VBC.
Focus on the future
As regulation continues to support innovation in using health care data, the safe and secure availability of such data is driving better care. As providers share in more risk, they’ll continue to use data to close care gaps, address SDOH, and seek integration solutions for VBC success. And as health systems and payers continue to grow more aligned, there will be even more data exchange and communication between parties about patient treatment.
Providers will need to find innovative ways to differentiate themselves, particularly as it relates to data sharing and ensuring a high-quality, seamless patient experience. As the industry resolves its challenges of data siloing, we support access and accountability, ushering in the proven outcomes of value-based care delivery.
Andy Kumar is vice president of product management for Ciox, a health care data management company based in Alpharetta, Georgia.